Strength comes in numbers

The other day I was attempting to cornrow my son's hair and boy is he tender headed. He was screaming and yelling, twitching and turning all of which was making me incredibly frustrated.  Finally I asked him- sarcastically, if he wanted me to cry with him and to my surprise he said yes! So I began to make crying sounds and before I knew it, my son's tears turned into laughs.  I finished his hair in record time and all because we "cried" together. This experience got me to thinking about the importance of support.

As a (stereo) typical Independent Black Woman I shudder at the thought of "needing" support. It actually makes me feel like I am weak. "I don't need anyone I can do it myself".  This is natural for me, having come from a family predominately made up of single mothers.  For me having a baby was no different. Prior to getting pregnant, I thought it would be all about me, but I learned that strength is definitely in numbers. 

Before having my own children, my most familiar story of birth was my own.  When my parents tell me the story of my birth, they say that when my mother was pregnant, they decided to have a natural birth. They took child birth classes and went to the hospital prepared to give birth naturally- or so they thought.  Just as is the common practice in most hospitals today, upon admittance my mother was refused all solid foods. My father tells me that the nurses and doctors repeatedly asked my mother if she wanted to get the epidural anesthesia (seems not much has changed in 30 years), however they remained strong in their decision to have a natural birth.

At one point my father leaves the room and comes back "with onions on his breath" as my mom says with the "I know he didn't" voice. At that point my mother's labor became extremely uncomfortable, and right on cue the doctor asked again if she wanted to get the epidural. Only this time my mother says yes, and my father says no. When my father tries to override my mother the doctor snaps "I wasn't talking to you sir".  Well as the story goes my mom got the epidural and that started a whole bunch of complications- but that's another story.   The second time around my mother and father remained unified. My father says he starved with my mother and gave more hands on support.  Needless to say my mom gave birth to my younger brother naturally. 

As for me I found out that I wasn't as independent as I thought, at least not when it came to giving birth. As it turned out I needed lots of support; I had a challenging labor with my son and I leaned on everyone- my mom, grandmother, aunt, and my best friend.  My rock though was my loving husband. He held me, comforted me and encouraged me, hands on steadily and consistently from start to finish.  I could not have imagined what I would have done with out him.

When we go through difficult times with someone else, especially a loved one, the challenge doesn't seem so difficult. This is especially true for labor and birth.  Having support can really mean the difference between an unbearable experience and a beautiful birth experience.  So when you are planning the birth of your next child, consider taking a couples course- that trains both the mother and her support partner (the dad, grandmother, girlfriend etc.)  to be prepared for labor and birth.  Also consider hiring a Doula to come with her bag of tricks for professional support.

Chocolate & Wine Weaning Party











Rewards for a Mother's Sacrifices











There was no doubt in my mind that I would breastfeed my children. My mother had breastfed both my brother and I. As a child, most of the mother's I knew breastfed their children too.  I had no idea that I would be one of a very small group of Black women to Breastfeed beyond one month.

When I got pregnant with my first child, I was at the height of my twenties.  Old enough to drink, get into the club and young enough to do it on a regular basis without being a lush or needing a month of recuperating time.  When I found out that I was pregnant I knew that things had to drastically change if I was going to be the type of mother I had planned to be. 

This change came easy while I was pregnant. I mean it is NOT sexy to be in the club with a big baby bump. However once the baby was born thats when I started to miss those things that I had given up.











I loved my child as much as one person could love another, but there were times where I felt burdened and saddened that I could do or have the things that I did before I was a mom. I also noticed that the formula feeding moms seemed to have more "freedom".  Their babies seem to sleep longer, and eat less frequently. Not to mention the option to leave the baby for extended periods of time.

Still with the allure of formula I couldn't give up the breastfeeding.  To me the benefits far outweighed the negatives. There are many many benefits to breastfeeding, but for me the biggest reasons were:

1. My pregnancy weight (of almost 50 lbs) just melted away.- I got to eat more while doing it and I am ashamed to say, I didn't even do any exercise... I probably could have lost even more if I had did a sit up or two.

2. I didn't loose much sleep- The baby slept in the room with me and sometimes in the same bed (read about safe co sleeping) and when my son needed to eat at night I would just pop the "ninny" in his mouth. By the time he was 3 months we were on a self serve program, I didn't have to wake up at all.

3. My son didn't get sick - including ear infections. My son didn't get a so much as a cold until he was 2 years old, and even then until today his colds don't last longer than 48 hours. He doesn't even get sluggish.

4. No diaper rashes- Saved a bunch of money on extra diapers and that cream stuff.

5. The best benefit to me was that my son was getting the best healthy start. Nowadays children are getting more diseases that used to only effect older people. It scares me to think that my children may live a long life of suffering through any of those diseases.

Or worse if my children only live a short life because of health problems that could be avoided with a small sacrifice of 1-2 years of my life to breastfeed. 

All that said, it hard to remember when I was the only one who could remember this past New Years party.  So what I did was plan my own party...a Chocolate and Wine Weaning Party to reward my self for all the sacrifices I have made to be the best mother I can be.

I encourage all mothers to breastfeed for at least the first year.  Contrary to popular belief, it is RARE that a mother is unable to successfully breastfeed.  If you have concerns seek out help and support:

African American Breastfeeding Alliance



African American Breastfeeding Guide



African American Breastfeeding



Mocha Milk

Epidural

From Wikipedia, the free encyclopedia

The term epidural is often short for epidural anesthesia, a form of regional anesthesia involving injection of drugs through a catheter placed into the epidural space. The injection can cause both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of pain signals through nerves in or near the spinal cord.

The epidural space (sometimes called the extradural space or peridural space) is a part of the human spine inside the spinal canal separated from the spinal cord and its surrounding cerebrospinal fluid by the dura mater.

Epidural anesthesia

Indications

Injecting medication into the epidural space is primarily performed for analgesia. This may be performed using a number of different techniques and for a variety of reasons. Additionally, some of the side-effects of epidural analgesia may be beneficial in some circumstances (e.g. vasodilation may be beneficial if the patient has peripheral vascular disease). When a catheter is placed into the epidural space (see below), the effects of the analgesia may be prolonged for several days, if required. Epidurals may be used:

For analgesia alone, where surgery is not contemplated. An epidural for pain relief (e.g. in childbirth) is unlikely to cause loss of muscle power, but is not usually sufficient for surgery.

As an adjunct to general anaesthesia. The anaesthetist may use epidural analgesia in addition to general anaesthesia. This may reduce the patient's requirement for opioid analgesics. This is suitable for a wide variety of surgery, for example gynaecological surgery (e.g. hysterectomy), orthopaedic surgery (e.g. hip replacement), general surgery (e.g. laparotomy) and vascular surgery (e.g. open aortic aneurysm repair). See also caudal epidural, below.

As a sole technique for surgical anaesthesia. Some operations, most frequently Caesarean section, may be performed using an epidural anaesthetic as the sole technique. Typically the patient would remain awake during the operation. The dose required for anaesthesia is much higher than that required for analgesia.

For post-operative analgesia, in either of the two situations above. Analgesics are given into the epidural space for a few days after surgery, provided a catheter has been inserted. Through the use of a patient-controlled analgesia (PCA) infusion pump, a patient may be given the ability to control post-surgical pain medications administered through the epidural.

For the treatment of back pain. Injection of analgesics and steroids into the epidural space may improve some forms of back pain. See below.

For the treatment of chronic pain or palliation of symptoms in terminal care, usually in the short or medium term.

A patient getting a modern epidural for pain relief generally receives a combination of local anesthetics and opioids. Common local anesthetics include lidocaine, bupivicaine, ropivicaine, and chloroprocaine. Common opioids are morphine (or hydromorphone), fentanyl, sufentanil, and pethidine (known as meperidine in the U.S.). These are then injected in relatively small doses. Occasionally other agents may be used, such as clonidine or ketamine.

Because of the nature of epidurals, they are most suitable for analgesia for the abdomen, pelvis or legs. They are much less suitable for analgesia for the chest, neck, or arms and are not possible for the head.

http://en.wikipedia.org/wiki/Epidural

A local anesthetic is a drug that reversibly inhibits the propagation of signals along nerves. When it is used on specific nerve pathways, effects such as analgesia (loss of pain sensation) and paralysis (loss of muscle power) can be achieved.

Clinical local anesthetics belong to one of two classes: aminoamide and aminoester local anesthetics. synthetic local anesthetics are structurally related to cocaine. They differ from cocaine mainly in that they have no abuse potential and do not act on the sympathoadrenergic system, i.e. they do not produce hypertension or local vasoconstriction.

An opioid is a chemical substance that has a morphine-like action in the body. The main use is for pain relief. These agents work by binding to opioid receptors, which are found principally in the central nervous system and the gastrointestinal tract. The receptors in these two organ systems mediate both the beneficial effects, and the undesirable side effects. There are four broad classes of opioids:

endogenous opioid peptides (opioids produced naturally in the body);

opium alkaloids, such as morphine (the first alkaloid isolated from opium) and codeine;

semi-synthetic opioids, such as heroin and oxycodone; and

fully synthetic opioids, such as pethidine and methadone.

Although the term opiate is often used as a synonym for opioid, it is more properly limited to the natural opium alkaloids and the semi-synthetics derived from them.

http://en.wikipedia.org/wiki/Opioid

For more information look up the use, side effects and complications of the individual drugs used in epidurals:

Common local anesthetics include lidocaine, bupivicaine, ropivicaine, and chloroprocaine. Common opioids are morphine (or hydromorphone), fentanyl, sufentanil, and pethidine (known as meperidine in the U.S.).

Cytotec Induction and Off-Label Use

by Marsden Wagner, MD, MS

© 2003 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 67, Fall 2003.]

Illustrations by Jennifer Rosenberg

Without adequate testing of Cytotec (misoprostol) for labor induction, obstetricians simply began to use it on their birthing women. They were taking advantage of a huge loophole in our drug regulatory system. Once a drug is approved by the FDA for a specific medical indication and put on the market, there is absolutely nothing to prevent any doctor from using that drug for any indication, in any dose, for any patient he or she chooses. Since the label of the drug contains the indications approved by the FDA, this is called "off-label" use of a drug.

When obstetricians using Cytotec induction are confronted about their willingness to use a drug "off-label," they inevitably answer: "We use drugs off-label all the time." There are several serious problems with this answer. First, in reality, using Cytotec for induction is not "off-label" at all—it is "on-label contraindicated." On the Cytotec label it is explicitly written that this drug is contraindicated for use on pregnant women. Contraindication would not be on the label unless data exist suggesting possible serious risks from such use. "On-label contraindicated" is a whole different level of risk-taking than a use that is not mentioned one way or the other on the label.

A second reason to be concerned with the offhand answer of some obstetricians is that all off-label use is lumped together as though there were equal risks involved. During a case I was involved in, I asked the obstetrician about the off-label use of Cytotec for labor induction. He replied with the same answer that I have heard from so many clinicians: "We use Cytotec off-label for induction just like we use other drugs off-label all the time." Compare this to someone involved in a fatal car accident who is asked why he did not follow traffic laws and drove 100 miles an hour in a 25 mile an hour zone. The driver answers: "Traffic laws are disobeyed all the time. Why just last week there were dozens of parking tickets given out in this city." You can't compare the risks of excessive speeding with the risks of illegal parking. And you can't compare the risks of Cytotec induction with the risk involved in giving other drugs to pregnant women off-label. A survey of 731 pregnant women revealed they had been given 10 drugs while pregnant (1). But of the 10 drugs given off-label, the use of nine of them on pregnant women carried very little risk while the use of the tenth drug, the prostaglandins (including Cytotec), have proven serious risks including uterine rupture, following which one in four babies die.

Another problem with the excuse "we give drugs off-label all the time" is that the doctors using it are taking matters into their own hands when it comes to the use of drugs on their patients. They are unwilling to wait for the scientific evidence that shows whether this use of the drug is safe. This represents both a cavalier disregard for the safety of women and babies and a total lack of faith in the drug regulatory system.

Those doctors and midwives using Cytotec for induction of labor off-label need to understand that they are taking very big chances with the safety of the women and babies they serve. Just about everyone in the world, after taking a careful look at the scientific evidence, has concluded we don't yet know enough about the risks to be willing to use it. This is illustrated in the following list of organizations that do and do not recommend Cytotec (misoprostol) for labor induction:

Recommends

American College of Obstetricians and Gynecologists (ACOG)

Does not recommend

U.S. Food and Drug Administration

Best scientific opinion—Cochrane Database

Searle (manufacturer of Cytotec)

Society of Obstetricians and Gynaecologists of Canada

British Royal College of Obstetricians and Gynecologists

All obstetric organizations in Scandinavia

FIGO (International Federation of Gynecology and Obstetrics)

World Health Organization

Obstetric organizations and drug regulatory agencies in many other countries

How can ACOG possibly be willing to stand alone in opposition to the best scientific opinion in the world? Because so many of ACOG's members already use Cytotec induction off-label for its incredible convenience, the organization needs to support its members by recommending this practice. This means ACOG must find a paper published in a prominent U.S. journal supporting Cytotec induction. In ACOG's recommendation on Cytotec induction, the organization leans heavily on a paper by A.B. Goldberg and other authors published in the New England Journal of Medicine (2). Let's take a careful look at the contents of this paper, as it is a superb example of torturing the data until it confesses to what the authors want it to say:

"Prescribing a medication for an off-label indication is common in the treatment of pregnant women." This argument has no justification. Common usage of something does not prove it is a good idea. Experience in medical practice can often mean gaining more and more confidence in a mistake. Furthermore, as we have seen, some drugs have no serious risks involved while others carry very serious risks. And such widespread off-label prescribing is not found in other fields of medical practice.

Next, off-label use "is not considered experimental if based on sound scientific evidence." The whole purpose of on-label use is to guarantee the consumer that there is sound scientific evidence. With the off-label use of Cytotec for labor induction there are several problems:

First, no one can disagree that for a number of years in the early 1990s Cytotec was in widespread use before there was any sound scientific evidence. No one even knew what the proper dose should be and everyone was experimenting with dosage and protocol. I find no concern from ACOG or many individual obstetricians with this indisputable fact. Thousands of women were given Cytotec without knowing that it was off-label and experimental, thus giving them no opportunity for informed consent. Proof of the danger of such nonevidence-based practice came in 1999, when there was enough evidence showing the danger of Cytotec use in VBAC that even ACOG came out against it. How many women with VBAC were given Cytotec induction between 1990 and 1999? Almost certainly thousands. How many ruptured uteri? Almost certainly hundreds. How many babies died? Almost certainly dozens. How many women died? We know there were at least several. But today, rather than using this experience to push for more evidence before use, ACOG and some individual obstetricians are pushing for more use of Cytotec when its safety is still in serious doubt.

Second, who decides when there is "sound scientific evidence"? Here there is no agreement. ACOG says there is good data to support Cytotec induction. But ACOG is not a scientific body; it is an organization of professionals—a trade union trying to protect the interests of its members. The paper's authors agree with ACOG, but a careful look at their own review shows a very flimsy database on risks. They never directly say that Cytotec induction is "safe," nor do they say that we know enough about its risks. In fact, they say the opposite.

The authors greatly confuse the reader by lumping together all uses of Cytotec during pregnancy: first trimester medical abortion, induction of labor, postpartum hemorrhage. Each of these indications has very different data and should never be combined. "Two hundred studies involving a total of more than 16,000 women" is falsely inflating the data and is most misleading. The number of studies on Cytotec labor induction is far fewer. Most of them are not randomized experimental trials, and all of them, trials included, are too small to have sufficient statistical power for the less common but catastrophic risks such as uterine rupture, perinatal mortality and maternal mortality.

The paper has a section titled "Misoprostol in the Third Trimester of Pregnancy." The first part of this section is devoted to efficacy (not risk); no one is debating the effectiveness of this drug. The debate is with the risks and here the authors admit there is more "uterine hyperstimulation with associated changes in fetal heart rate" and more "meconium-stained fluid." The authors also write, "because there were so few serious adverse effects, the relative risk of rare adverse outcomes with the use of misoprostol for labor induction remains unknown." (Italics mine.) So these authors never say this drug is safe for induction and admit that with regard to risks, we don't know enough! The last paragraph in this section is a review of studies trying to find the correct dosage for Cytotec induction. Here, the authors point out that only recently has there been any kind of idea about dosage amount. This was because researchers were trying to lower one of the documented risks—uterine hyperstimulation. In this nine-page paper, there were only a few sentences about the risks of Cytotec induction. These sentences admit that the risk of adverse outcomes remains unknown. This is a very weak evidence base and can in no way be considered "sound scientific evidence."

In the section titled "Induction of Labor in Women with Previous Cesarean Section," the authors review the research showing the huge increase in risk of uterine rupture in VBAC if Cytotec induction is used and correctly conclude that it should not be used in this way. They never mention that the paper showing the risk of uterine rupture with Cytotec induction in VBAC was published in 1999, a decade after Cytotec induction had been used on large numbers of VBAC women.

In fact, because the number of cases of uterine rupture being reported was on the increase in the 1990s, ACOG responded with a recommendation that VBAC be done only in the hospital with an obstetrician and anesthesiologist at the ready. This recommendation made the organization's obstetrician members happy but was a disaster for birthing women, midwives, family physicians and small hospitals. ACOG, instead of recommending stopping Cytotec induction, recommended surrounding women having VBAC with experts to deal with the rupture when it happens. This would be like children drowning in a lake at summer camp and, instead of teaching the children to swim, the counselors put a couple of life preservers in the lake. ACOG has yet to do the obvious and demand research to monitor uterine ruptures to determine the reason for the increase and the likely relationship to Cytotec and other forms of induction.

While one paper quoted by ACOG clearly shows the increased risk of uterine rupture if prostaglandin gels are used in VBAC (3), I have been unable to find any research which looks at the contribution that Cytotec induction makes to this increase. We know that the incidence of uterine rupture has increased overall, but we do not know how Cytotec specifically factors in to this increase. The risk of uterine rupture after VBAC is 1 in 200 births, while the risk of uterine rupture with VBAC using Cytotec induction is 1 in 20 births—a tenfold increase. Because we know that the rate of induction of labor in the U.S. doubled in the 1990s, resulting in a convenient and significant increase in the rate of births Monday through Friday (4), it is quite likely that the increase in uterine rupture reported was related to the increase in induction, especially with Cytotec. Therefore, the ACOG recommendation on VBAC is not justified.

Goldberg and the other authors conclude in their paper that there is strong and consistent evidence to support the use of misoprostol for induction in the third trimester. This opinion is most inconsistent with the little data they present on the serious adverse effects (risks) of Cytotec induction. Their opinion is nevertheless used by ACOG. Because of the enormous advantages of Cytotec induction to the practicing obstetrician, the opinion is suspect. As the previous list shows, there is a large group of experts that disagrees with this opinion, believing the evidence is still insufficient to support Cytotec's use in labor induction when existing evidence gives strong indications of several serious risks. When there is disagreement on the evidence among the experts, the most conservative and safest course for the clinician to follow is the fundamental principle of medical practice: first do no harm.

Doctors find it difficult to admit mistakes. Here we have a big mistake—Cytotec induction with VBAC—that went on for years. Yet, there is no discussion of the error or what to do so it won't happen again.

Marsden Wagner, MD, MS, is a perinatologist, neonatalogist and perinatal epidemiologist from California who is an outspoken supporter of midwifery. He was responsible for maternal and child health in the European Regional Office of WHO for 14 years. Marsden travels all over the world to talk about appropriate uses of technology in birth and utilizing midwives for the best outcome. His book Pursuing the Birth Machine is a must for anyone involved in birth. Click here for a complete biography.

Notes

Rayburn, W. and Farmer, K. (1997). Off-Label Prescribing during Pregnancy. Obstetrics and Gynecology Clinics of North America 24 (3): 471–8.

Goldberg, A.B., Greenberg, M.B. and Darney, P.D. (2001). Drug Therapy: Misoprostol and Pregnancy. NEJM 344 (1): 38–47.

Lydon-Rochelle, M., Holt, V., Easterling, T. and Martin, D. (2001). Risk of Uterine Rupture during Labor among Women with a Prior Cesarean Delivery. NEJM 345 (1): 3–8.

For detailed data on childbirth in the U.S. collected by the federal government, including intervention rates and birth by the day of the week, go to www.cdc.gov/nchs/birth.

http://www.midwiferytoday.com/articles/cytotec.asp

EPIDURAL